Healthcare Provider Details

I. General information

NPI: 1891290516
Provider Name (Legal Business Name): KRISTOFER WILLERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KRISTOFER JOONDEPH-BREIDBART MD

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 W 27TH ST RM 5S
NEW YORK NY
10001-6208
US

IV. Provider business mailing address

32 MADISON ST # 2
SOMERVILLE MA
02143-1209
US

V. Phone/Fax

Practice location:
  • Phone: 833-351-8255
  • Fax: 888-815-3583
Mailing address:
  • Phone: 617-804-7970
  • Fax: 617-203-6011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number314147-01
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA177531
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number288089
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: